The Patriot X POS PlanWhen using in-network providers, Aetna's Patriot X POS Plan offers a $10 copay to visit your Primary Care Provider (PCP), and $15 specialist visits within the Aetna network. |
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IMPORTANT: The benefits listed in this chart are for illustrative purposes only. Specific benefit coverage information for your plan may vary. Please consult your Plan Document for particulars. All payments are based on reasonable and customary fees for the service provided. |
Please note that this plan is NOT available to all participants. Please contact your BMED consultant for more information.
| Type of Service | In Network w/ referral |
Out of Network |
| Deductible | ||
| Individual | None | $100/cal year |
| Family | None | $200/cal year |
| Coinsurance | None | 80/20 |
| Annual Out Of Pocket Max | ||
| Individual | N/A | $400 |
| Family | N/A | $1,200 |
| Lifetime Maximum | N/A | $1,000,000 |
| Primary/Preventive Care | ||
| PCP Office Visits | $10 Copay | Deductible & Coinsurance |
| Physical Exams | $10 Copay | 100% (to a maximum of $150) |
| Routine WellBaby Care | $10 Copay | 100% (to a maximum of $150) |
| Immunizations | $10 Copay | 100% |
| Routine Eye Exams | $15 Copay | Not Covered |
| Eyeglasses/Contact Lenses | $70 every 2 yrs plus discount | Not Covered |
| Specialty Care | ||
| Office Visits | $15 Copay | Deductible & Coinsurance |
| Maternity Care | $15 first visit, balance at 100% | Hospital at 100%; doctor subject to deductible & Coinsurance |
| X-Rays and Lab Tests | $15 Copay | 100% |
| Speech Therapy | $15 Copay (60 visits per consecutive day period per illness or injury) | 100% |
| Physical Therapy | $15 Copay (60 visits per consecutive day period per illness or injury) | 100% |
| Chiropractic | $15 Copay (max 20 visits) | 100% |
| Hospice | 100% | 100% |
| Durable Medical Equipment | Deductible & Coinsurance | Deductible & Coinsurance |
| Radiation/Chemotherapy Outpatient | 100% | 100% |
| Inpatient Services | ||
| Hospital Inpatient | 100% | 100% |
| Skilled Nursing Facility | 100% | 100% |
| Surgery and Anesthesia | ||
| Preadmission Testing | 100% | 100% |
| Physician Charges | 100% | 100% |
| Alcohol Dependency Treatment | ||
| Inpatient | 100% | 100% |
| Outpatient | Office visit copay | Deductible & Coinsurance |
| Inpatient Drug Dependency Treatment | ||
| Detoxification | 100% | 100% (max 7 days) |
| Inpatient Rehab | 100% (30 days) | 100% (30 days) |
| Outpatient Rehab | $15 Copay (60 visits) | Deductible & Coinsurance (30 visits) |
| Outpatient Drug Dependency Treatment | ||
| Outpatient | $15 Copay (60 visits) | Deductible & Coinsurance (30 visits) |
| Mental Health Treatment | ||
| Inpatient Treatment | 100% (35 days) | 100% (21 days) |
| Outpatient Treatment | $25 Co-pay (20 visits) | Deductible & Coinsurance |
| Emergency Care | ||
| Emergency Room | $35 Copay | $35 Copay |
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Note: This is only intended to be a general outline of some of the benefits when using the network of the Aetna Patriot X POS Plan and is not a binding schedule of benefits, fees or allowances. Consult your Plan Document for complete details of referral process, maximum visits permitted and other allowances |